Best Medications for Impulsivity
For treating impulsivity, stimulant medications (methylphenidate and amphetamine formulations) are the first-line pharmacological treatment, with atomoxetine as an effective alternative when stimulants are contraindicated or ineffective. These medications have the strongest evidence base for reducing impulsive behaviors across various populations.
First-Line Treatments
Stimulant Medications
Methylphenidate formulations:
Amphetamine formulations (including Adderall):
- Starting dose: 5-10 mg daily
- Maximum dose: Up to 50 mg daily
- Mechanism: Inhibits dopamine and norepinephrine transporters, affects vesicular monoamine transporter 2 1
Second-Line Treatment
- Atomoxetine (Strattera):
- Starting dose: 40 mg daily
- Target dose: 80 mg daily (1.2 mg/kg/day)
- Mechanism: Selective norepinephrine reuptake inhibitor 3
- Particularly useful when:
- Stimulants are contraindicated
- Substance abuse concerns exist
- Patient has comorbid anxiety
- Evidence: Significantly reduces premature responding (impulsivity) at both 1 mg/kg and 3 mg/kg doses 4
Third-Line Treatments
Alpha-2 Adrenergic Agonists
Guanfacine (Intuniv XR):
- Starting dose: 1 mg once daily
- Target dose: 1-7 mg daily (0.05-0.12 mg/kg/day)
- Less evidence for impulsivity specifically 4
Clonidine:
- Starting dose: 0.05 mg twice daily
- Maximum dose: Based on response and side effects
- Limited evidence for impulsivity specifically
Treatment Selection Algorithm
First attempt: Trial of methylphenidate formulation
- If effective with tolerable side effects → continue
- If ineffective or intolerable side effects → switch to amphetamine formulation
Second attempt: Trial of amphetamine formulation
- If effective with tolerable side effects → continue
- If ineffective or intolerable side effects → switch to atomoxetine
Third attempt: Trial of atomoxetine
- If effective with tolerable side effects → continue
- If ineffective or intolerable side effects → consider alpha-2 agonists
Fourth attempt: Trial of guanfacine or clonidine
- If effective with tolerable side effects → continue
- If ineffective → consider combination therapy or psychiatric consultation
Monitoring and Side Effects
For Stimulants
- Monitor blood pressure, heart rate, weight, appetite, sleep patterns
- Common side effects: decreased appetite, sleep disturbances, increased blood pressure/heart rate, headaches, irritability 1
- Cardiovascular assessment before starting stimulants is recommended
For Atomoxetine
- Monitor for suicidal thoughts, especially in children and adolescents
- Monitor liver function (rare risk of severe liver damage)
- Common side effects: nausea, decreased appetite, fatigue, mood swings 3
For Alpha-2 Agonists
- Monitor blood pressure and heart rate (risk of hypotension)
- Common side effects: sedation, fatigue, dizziness, dry mouth
Special Considerations
- Substance abuse history: Consider atomoxetine over stimulants due to lower abuse potential 5
- Comorbid anxiety: Atomoxetine may be preferred as it can help with both conditions
- Cardiovascular concerns: Thorough cardiovascular assessment before starting stimulants; alpha-2 agonists may be preferred in some cases
- Sleep issues: Consider timing of medication administration; extended-release formulations in the morning may minimize sleep disruption
Cautions
- Avoid benzodiazepines for impulsivity management due to risk of tolerance, addiction, and potential paradoxical reactions 5
- Antipsychotics should generally be reserved for cases with comorbid psychotic symptoms or severe agitation unresponsive to other treatments 5
- For patients with impulsivity related to medical conditions, stimulant dosages should be approximately half the starting dose for ADHD and titrated slowly 5
The evidence strongly supports stimulant medications as the most effective pharmacological intervention for impulsivity, with atomoxetine as a valuable alternative when stimulants are not appropriate.